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The Persistent Issue of ACL Ruptures in Female Footballers: A Long-Standing Concern

ACL ruptures in women

Recent media coverage in the UK has brought attention to a seemingly alarming rise in ACL (Anterior Cruciate Ligament) ruptures among female footballers. However, it's important to note that this issue is not a new phenomenon but rather a long-standing concern within the realm of women's football. For decades, researchers and sports medicine professionals have recognised the heightened prevalence of ACL injuries in female footballers. In this blog post, we will delve into the factors contributing to the enduring problem of ACL ruptures in female football and explore why it's not a recent development. The author will also provide his opinions on why this 'epidemic' (as it has been referred to for years) is not abating.

Biomechanical Variations: A Long-Recognised Factor

One of the factors contributing to ACL injuries in female footballers is biomechanical variations between males and females. These differences have been known to exist for quite some time. Women typically have a wider pelvis and a greater Q-angle, which affects knee joint mechanics and can increase susceptibility to ACL tears. Researchers have been studying these anatomical distinctions for decades, shedding light on the underlying biomechanical factors.

Hormonal Influence: A Recognised Variable

Hormonal influences on ACL injuries have also been a subject of study for a considerable period. Estrogen, in particular, has been associated with changes in ligament laxity. The fluctuation of hormones throughout the menstrual cycle can affect the stability of the ACL. Researchers have been investigating the hormonal aspect of ACL injuries in female athletes for many years, emphasising its significance in injury risk.

Neuromuscular Control: A Decades-Old Focus

The importance of neuromuscular control in preventing ACL injuries has been emphasised by sports scientists and medical professionals for decades. Studies have shown that female athletes may exhibit lower neuromuscular control compared to males, making them more vulnerable to ACL tears. This understanding has informed the development of targeted training programs to enhance neuromuscular control among female footballers.

Ignoring knee rotation: This author's biggest concern One area that tends to get missed is the need to work on a joint by joint basis for the Footballer as opposed to focusing too much on the overall system of movement (lunges, squats etc). One particularly ignored range of motion is the rotational component of the knee.

The knee is supposed to rotate 10-20 degress of internal rotation and 10-20 degrees of external rotation. However, these ranges of motion are often ignored. It is also worth remembering that having this range of rotation is one thing, having strength and control of it is another.

Why should knee rotation be trained? Well, think about most sports knee injuries, most of them occur with a degree of rotational movement. It is well known that ACL ruptures mainly occur from an internal twist of the knee usually in a valgus (inward) direction. So why is specific knee rotation through a full range not a movement that is trained more frequently in football as part of a preventative strategy?

Hypermobility: 10-20% of the population still being ignored

The Beighton scale is a way of determining if you have signs of hypermobility, 10-20% of the population are hypermobile to some degree and females are more likely to be hypermobile. This population will have a very good joint range of motion but it does not mean they are strong through it. So in the example of knee rotation, some may lack the required amount of rotation, whereas others may have the range but not the ability to control it fully). How many athletes are screened for this? How many of them are therefore not getting exercises that are designed to address their excess (AKA hyper) passive range of motion. The passive ranges of motion at a joint is where we are weakest and most prone to injury, so by not addressing the strengh deficit here, we are leaving the athlete vulnerable. The term hypermobility needs addressing as it implies strength through a large range of motion, it should be referred to hyperflexibility as this is how it presents clinically with a lack of strength through a larger passive end range. It is always worth remembering the difference between mobility and flexibility when designing an exercise plan.

Training and Conditioning: A Longstanding Concern

The need for specialised and comprehensive training and conditioning programs for female footballers has been acknowledged by experts for an extended period. Historically, female athletes have not always received the same level of attention and specialised training as their male counterparts, which has contributed to the persistent issue of ACL injuries. This has what has been highlighted recently in the UK media.


The recent media attention on ACL ruptures among female footballers should not be seen as an emergence of a new issue. Rather, it highlights the ongoing challenge that women's football has faced for decades. Understanding the multifaceted factors contributing to ACL injuries in female footballers is crucial to developing effective prevention strategies and ensuring the long-term health and success of female athletes in the sport. It's important to recognise that the persistence of this issue underscores the need for continued research, education, and investment in women's football to mitigate the risk of ACL injuries.


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